<div class="form_container">
	<div class="field-row">
	    <div class="field-label">{translate}Grand total{/translate}</div>
	    <div class="field-value" style="width: 140px; text-align: right;"><span class="field"  id="totalPatientPrice">{$grandTotal}</span></div>
	    <div style="clear: both;"></div>
	</div>
	<div class="field-row">
        <div class="field-label">{translate}Insurance payment{/translate}</div>
        <div class="field-value" style="width: 140px; text-align: right;"><span class="field">{$insurancePrice}</span></div>
        <div style="clear: both;"></div>
    </div>
    <div class="field-row">
        <div class="field-label">{translate}Total patient price{/translate}</div>
        <div class="field-value" style="width: 140px; text-align: right;">
                <span class="field" id="remainingAmount">{$patientPrice}</span>
            </div>
        <div style="clear: both;"></div>
    </div>
	<div class="field-row">
	    <div class="field-label">
	        {translate}Advance payment{/translate}
	    </div> 
	    <div class="field-value" style="width: 140px; text-align: right;">	        
	            <span class="field">{$realPayment}</span>
	    </div>
	    <div style="clear: both;"></div>
	</div>
	<div class="field-row">
	    <div class="field-label">{translate}Patient's debt{/translate}</div>
	    <div class="field-value" style="width: 140px; text-align: right;"><span class="field">{$remainingAmount}</span></div>        
	    <div style="clear: both;"></div>
	</div>
	
</div>